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Towards Evidence-Based Circumcision of English Boys

Anthony MK Rickwood, Simon E Kenny, and Steven C Donnell

Objective: To assess the extent to which recent trends in medical circumcision of English boys match the incidence and age-distribution of preputial pathology.
Design: Analysis of circumcision rates both overall and in various age ranges. Analysis of the age-distribution of preputial pathology among boys referred for circumcision.
Setting: England (1984-98), former Mersey Region (1975-97), Liverpool Children’s Hospitals (1975-97), BUPA subscribers (1992-7).
Subjects: Boys aged 0 -14 years.
Results: Crude circumcision rates in the mid-1980's were geographically uniform (»4.2/000 boys/annum): the most recent corresponding rates are England 2.5, BUPA subscribers 2.3, Mersey Region 2.2, Liverpool Children’s Hospitals 1.0. Among various age ranges, boys aged 2-4 years experienced both the maximum rates of circumcisions and the steepest subsequent declines (England 9.7 to 4.5, Mersey Region 9.3 to 3.7, Liverpool Children’s Hospitals 9.5 to 0.9) Only among boys aged 10-14 years have circumcision rates remained both static and geographically uniform. In England and in the Mersey Region »90% of circumcisions were indicated for ‘phimosis’. Among 1014 boys referred for circumcision (Urology Department, Liverpool Children’s Hospital), only 3 examples of pathological phimosis were seen in
boys aged 0-4 years whereas this diagnosis was common among those aged 10-14 years (60/135).
Conclusions: Recent trends in medical circumcision of English boys are consistent with the age-distribution of preputial pathology but not, as yet, with the incidence of such pathology. The principal deficiency in practice remains over-diagnosis of phimosis in young boys. The number of boys medically circumcised has declined from »22,400 in 1992/3 to »12,200 in 1997/8: a realistic target figure of 2% of boys circumcised for medical indications would have »6000 fewer circumcisions annually.